Longitudinal Oral Anticoagulant Adherence Trajectories in Patients With Atrial Fibrillation

Adherence to istradefylline in patients with Parkinson's disease: A group-based trajectory analysis

BACKGROUND

Understanding the different patterns of adherence to istradefylline treatment is essential to identifying Parkinson's disease (PD) patients who might benefit from targeted interventions.

OBJECTIVES

This descriptive study aimed to identify longitudinal istradefylline adherence patterns and to characterize factors associated with them.

METHODS

We identified PD patients aged 21-99 years who initiated istradefylline treatment in a Japanese hospital administrative database. Group-based trajectory modeling was used to model the monthly proportion of days covered over time to identify distinct 360-day adherence patterns. Factors associated with each adherence pattern were assessed using univariable multinomial logistic regression models.

RESULTS

Of 2088 eligible PD patients, 4 distinct adherence groups were identified: consistently high adherence (56.8%); rapidly declining adherence (25.8%); gradually declining adherence (8.5%); and gradually declining and then recovering adherence (9.0%). Compared to the consistently high adherence group, the other groups had the following characteristics associated with a likelihood of lower adherence: the rapidly declining adherence group received fewer dopamine agonists (63.8% vs. 69.4%), monoamine oxidase B (MAO-B) inhibitors (26.8% vs. 31.6%), and catechol-O-methyl transferase inhibitors (31.6% vs. 37.0%) and had a higher prevalence of anxiety/mood disorders (29.9% vs. 24.6%); the gradually declining adherence group received fewer MAO-B inhibitors (22.5% vs. 31.6%) and amantadine (8.4% vs. 16.1%) and had a higher prevalence of mild cognitive impairment/dementia (27.0% vs. 18.8%); and the declining and then recovering adherence group had a higher prevalence of anxiety/mood disorders (34.2% vs. 24.6%).

CONCLUSIONS

Clinicians should be aware of the heterogeneous patterns of adherence to istradefylline.

Development and Application of an Attribute-Based Taxonomy on the Benefits of Oral Anticoagulant Switching in Atrial Fibrillation: A Delphi Study

INTRODUCTION

Patients with atrial fibrillation (AF) often switch between oral anticoagulants (OACs). It can be hard to know why a patient has switched outside of a clinical setting. Medication attribute comparisons can suggest benefits. Consensus on terms and definitions is required for inferring OAC switch benefits. The objectives of the study were to generate consensus on a taxonomy of the potential benefits of OAC switching in patients with AF and apply the taxonomy to real-world data.

METHODS

Nine expert clinicians (seven clinical pharmacists, two cardiologists) with at least 3 years of clinical and research experience in AF participated in a Delphi process. The experts rated and commented on a proposed taxonomy on the potential benefits of OAC switching. After each Delphi round, ratings were analyzed with the RAND Corporation/University of California, Los Angeles (RAND/UCLA) appropriateness method. Median ratings, disagreement index, and comments were used to modify the taxonomy. The resulting taxonomy from the Delphi process was applied to a cohort of patients with AF who switched OACs in a population-based administrative health dataset from 1996 to 2019 in British Columbia, Canada.

RESULTS

The taxonomy was finalized in two Delphi rounds, reaching consensus on five switch benefit categories: safety, effectiveness, convenience, economic considerations, and drug interactions. Safety benefit (a switch that could lower the risk of adverse drug events) had three subcategories: major bleeding, intracranial hemorrhage (ICH), and gastrointestinal (GI) bleeding. Effectiveness benefit had four subcategories: stroke and systemic embolism (SSE), ischemic stroke, myocardial infarction (MI), and all-cause mortality. Real-world OAC switches revealed that more OAC switches had convenience (72.6%) and drug interaction (63.0%) benefits compared to effectiveness (SSE 22.0%, ischemic stroke 11.1%, MI 3.1%, all-cause mortality 10.1%), safety (major bleeding 24.3%, GI bleeding 10.6%, ICH 48.5%), and economic benefits (12.1%).

CONCLUSIONS

The Delphi-based taxonomy identified five criteria for the beneficial effects of OAC switching, aiding in characterizing real-world OAC switching.

Adherence to direct or vitamin K antagonist oral anticoagulants in patients with atrial fibrillation: a long-term observational study

Our objectives were to measure long-term adherence to oral anticoagulants (OACs) in patients with atrial fibrillation (AF) and to identify patient factors associated with adherence. Using linked, population-based administrative data from British Columbia, Canada, an incident cohort of adults prescribed OACs for AF was identified. We calculated the proportion of days covered (PDC) as a time-dependent covariate for each 90-day window from OAC initiation until the end of follow-up. Associations between patient attributes and adherence were assessed using generalized mixed effect linear regression models. 30,264 patients were included. Mean PDC was 0.69 (SD 0.28) over a median follow-up of 6.7 years. 54% of patients were non-adherent (PDC < 0.8). After controlling for confounders, factors positively associated with adherence were number of drug class switches, history of stroke or transient ischemic attack, history of vascular disease, time since initiation, and age. Age > 75 years at initiation, polypharmacy (among VKA users only), and receiving DOAC (vs. VKA) were negatively associated with adherence. PDC decreased over time for VKA users and increased for DOAC users. Over half of AF patients studied were, on average, nonadherent to OAC therapy and missed 32% of their doses. Several patient factors were associated with higher or lower adherence, and adherence to VKA declined during therapy while DOAC adherence increased slightly over time. To min im ize the risk stroke, adherence-supporting interventions are needed for all patients with AF, particularly those aged > 75 years, those with prior stroke or vascular disease, VKA users with polypharmacy, and DOAC recipients.

2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association

BACKGROUND

The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2024 AHA Statistical Update is the product of a full year's worth of effort in 2023 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. The AHA strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional global data, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Trajectories of P2Y12 inhibitor adherence in patients with acute coronary syndromes

PURPOSE

P2Y12 inhibitors (P2Y12i) reduce cardiac events after acute coronary syndromes (ACS). However, suboptimal P2Y12i adherence persists. We aimed to examine P2Y12i non-adherence using group-based trajectory methods and to identify adherence predictors.

METHODS

We conducted a population-based, retrospective cohort study using administrative data in Ontario, Canada of patients ≥65 years admitted for ACS between April 2014 and March 2018 with a P2Y12i dispensed within 7 days of discharge. We used group-based trajectory models to characterize longitudinal 1-year adherence patterns. Predictors associated with each adherence trajectory were identified by multinomial logistic regression.

RESULTS

We included 11 917 patients using clopidogrel and 9763 using ticagrelor, aged [mean ± SD]: 77.33 ± 8.31/73.59 ± 6.79 years; men: 56.2%/65.4%, respectively. We identified 3 longitudinal adherence trajectories, that differed by agent: 75% of clopidogrel and 68% of ticagrelor patients showed a consistently adherent trajectory, while 13%/17% were gradually, and 12%/15% were rapidly non-adherent, respectively (p < 0.001). Differing baseline characteristics in each cohort were associated with observed adherence trajectories. Concomitant atrial fibrillation and prior bleeding history were associated with non-adherence among clopidogrel users. Among ticagrelor users, women and older persons were more likely to be rapidly non-adherent, adherence declining steeply starting 1 month post-ACS.

CONCLUSIONS

We identified distinct adherence trajectories for clopidogrel and ticagrelor post-ACS, with 3 out of 4 clopidogrel patients but only 2 out of 3 ticagrelor patients in the consistently adherent trajectory. Intensive interventions targeted to the period of steep adherence decline post-ACS, particularly for women and older persons initiating ticagrelor, and patients with atrial fibrillation on clopidogrel should be considered and investigated further.

Medication adherence trajectory of patients with chronic diseases and its influencing factors: A systematic review

AIMS

To synthesize the published studies on medication adherence trajectories among patients with chronic diseases and identify the influencing factors.

DESIGN

Systematic review.

DATA SOURCES

Medline (Ovid), Embase (Ovid) and Web of Science core collection were searched from database inception to 1 July 2022.

REVIEW METHODS

Potentially eligible articles were independently screened by three reviewers using set inclusion and exclusion criteria. The Joanna Briggs Institute critical appraisal checklist for cohort studies was used to appraise the quality of the included articles. Three reviewers independently evaluated the quality, extracted data and resolved differences by consensus. Results were presented using descriptive synthesis, and the prevalence of recategorised medication adherence trajectories was calculated from the published data.

RESULTS

Fifty studies were included. Medication adherence trajectories among patients with chronic diseases were synthesized into six categories: adherence, non-adherence, decreasing adherence, increasing adherence, fluctuating adherence and moderate adherence. Low and moderate evidence showed that (1) patient-related factors, including age, sex, race, marital status and mental status; (2) healthcare team and system-related factors, including healthcare utilization, insurance and primary prescriber specialty; (3) socioeconomic factors including education, income and employment status; (4) condition-related factors including complications and comorbidities and (5) therapy-related factors including the number of medications, use of other medications, and prior medication adherence behaviours were factors influencing the medication adherence trajectory. Marital status and prior medication adherence behaviour were the only influencing factors with moderate evidence of an effect.

CONCLUSION

The medication adherence trajectory among patients with chronic diseases varied widely. Further studies are warranted to determine contributory factors.

IMPLICATIONS FOR THE PROFESSION

Healthcare providers should be aware that patients' medication adherence has different trajectories and should take appropriate measures to improve patients' medication adherence patterns.

PATIENT OR PUBLIC CONTRIBUTION

None. As a systematic review, patients and the public were not involved.

Longitudinal Trajectory Modeling to Assess Adherence to Sacubitril/Valsartan among Patients with Heart Failure

Medication adherence in chronic conditions is a long-term process. Modeling longitudinal trajectories using routinely collected prescription data is a promising method for describing adherence patterns and identifying at-risk groups. The study aimed to characterize distinct long-term sacubitril/valsartan adherence trajectories and factors associated with them in patients with heart failure (HF). Subjects with incident HF starting sac/val in 2017-2018 were identified from the Campania Regional Database for Medication Consumption. We estimated patients' continuous medication availability (CMA9; R package AdhereR) during a 12-month period. We selected groups with similar CMA9 trajectories (Calinski-Harabasz criterion; R package kml). We performed multinomial regression analysis, assessing the relationship between demographic and clinical factors and adherence trajectory groups. The cohort included 4455 subjects, 70% male. Group-based trajectory modeling identified four distinct adherence trajectories: high adherence (42.6% of subjects; CMA mean 0.91 ± 0.08), partial drop-off (19.6%; CMA 0.63 ± 0.13), moderate adherence (19.3%; CMA 0.54 ± 0.11), and low adherence (18.4%; CMA 0.17 ± 0.12). Polypharmacy was associated with partial drop-off adherence (OR 1.194, 95%CI 1.175-1.214), while the occurrence of ≥1 HF hospitalization (OR 1.165, 95%CI 1.151-1.179) or other hospitalizations (OR 1.481, 95%CI 1.459-1.503) were associated with low adherence. This study found that tailoring patient education, providing support, and ongoing monitoring can boost adherence within different groups, potentially improving health outcomes.

It can be safe to discontinue oral anticoagulants after successful atrial fibrillation ablation: A systematic review and meta-analysis of cohort studies

BACKGROUND

Current guidelines recommended that oral anticoagulants (OACs) should last for a minimum first 2 months after atrial fibrillation (AF) ablation and the long-term decision of anticoagulation after AF ablation should be based on the individual patient's risk of stroke rather than the rhythm status. There is controversy about the safety of discontinuing OACs in patients with atrial fibrillation after the blanking period due to the divergences between consensus recommendations and clinical practice.

METHODS

Electronic bibliographic sources (PubMed, Embase, and Web of Science) were searched until August 2023 to identify cohort studies about the safety of discontinuing OACs in patients with AF after the blanking period. The primary outcome was thromboembolism (TE). The secondary outcome was major bleeding events (MBEs). Two authors extracted articles independently using predefined data fields. The pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated based on a random-effects model.

RESULTS

A total of 16 studies (11 prospective cohorts and 5 retrospective cohorts) enrolling 23,942 patients (14,382 OFF-OAC and 9560 ON-OAC) were included in our analysis. No significant difference emerged in the risk of TE between OFF-OAC and ON-OAC patients following AF ablation after the banking period (OR = 0.66; 95%CI, 0.43-1.01). Similar results emerged in the patients with a high risk of TE after stratification by the risk level of TE (OR = 0.72; 95%CI, 0.25-2.08). A significant reduction in incidences of major bleeding was found in the OFF-OAC patients compared with the ON-OAC patients (OR = 0.23; 95%CI, 0.12-0.42). Subgroup analyses for TE found a reduction of incidences in the subgroups who switched to antiplatelet drugs and with a follow-up duration <3 years. Subgroup analyses for MBEs found a significant reduction of incidences in all subgroups.

CONCLUSIONS

Our study suggests it can be safe to discontinue OACs after successful AF ablation. Discontinuation of OACs may reduce the risk of MBEs while not increasing the risk of TE.

Management of Patients Treated with Direct Oral Anticoagulants in Clinical Practice and Challenging Scenarios

It is well established that direct oral anticoagulants (DOACs) are the cornerstone of anticoagulant strategy in atrial fibrillation (AF) and venous thromboembolism (VTE) and should be preferred over vitamin K antagonists (VKAs) since they are superior or non-inferior to VKAs in reducing thromboembolic risk and are associated with a lower risk of intracranial hemorrhage (IH). In addition, many factors, such as fewer pharmacokinetic interactions and less need for monitoring, contribute to the favor of this therapeutic strategy. Although DOACs represent a more suitable option, several issues should be considered in clinical practice, including drug-drug interactions (DDIs), switching to other antithrombotic therapies, preprocedural and postprocedural periods, and the use in patients with chronic renal and liver failure and in those with cancer. Furthermore, adherence to DOACs appears to remain suboptimal. This narrative review aims to provide a practical guide for DOAC prescription and address challenging scenarios.

Adherence to Oral Antidiabetic Drugs in Patients with Type 2 Diabetes: Systematic Review and Meta-Analysis

Poor adherence to oral antidiabetic drugs (OADs) in patients with type 2 diabetes (T2D) can lead to therapy failure and risk of complications. The aim of this study was to produce an adherence proportion to OADs and estimate the association between good adherence and good glycemic control in patients with T2D. We searched in MEDLINE, Scopus, and CENTRAL databases to find observational studies on therapeutic adherence in OAD users. We calculated the proportion of adherent patients to the total number of participants for each study and pooled study-specific adherence proportions using random effect models with Freeman-Tukey transformation. We also calculated the odds ratio (OR) of having good glycemic control and good adherence and pooled study-specific OR with the generic inverse variance method. A total of 156 studies (10,041,928 patients) were included in the systematic review and meta-analysis. The pooled proportion of adherent patients was 54% (95% confidence interval, CI: 51-58%). We observed a significant association between good glycemic control and good adherence (OR: 1.33; 95% CI: 1.17-1.51). This study demonstrated that adherence to OADs in patients with T2D is sub-optimal. Improving therapeutic adherence through health-promoting programs and prescription of personalized therapies could be an effective strategy to reduce the risk of complications.

Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2023 Statistical Update is the product of a full year's worth of effort in 2022 by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. The American Heart Association strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional COVID-19 (coronavirus disease 2019) publications, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Medication non-adherence patterns and profiles for patients with incident myocardial infarction: Observations from a large multi-morbid US population

BACKGROUND

Consistent adherence levels to multiple long-term medications for patients with cardiovascular conditions are typically advocated in the range of 50% or higher, although very likely to be much lower in some populations. We investigated this issue in a large cohort covering a broad age and geographical spectrum, with a wide range of socio-economic disability status.

METHODS

The patients were drawn from three different health plans with a varied mix of socio-economic/disability levels. Adherence patterns were examined on a monthly basis for up to 12 months past the index date for myocardial infarction (MI) using longitudinal analyses of group-based trajectory modelling. Each of the non-adherent patterns was profiled from comorbid history, demographic and health plan factors using main effect logistic regression modelling. Four medication classes were examined for MI: betablockers, statin, ACE inhibitors and anti-platelets.

RESULTS

The participant population for the MI/non-MI cohorts was 1,987,605 (MI cohort: mean age 62 years, 45.9% female; non-MI cohort: mean age 45 years, 55.3% females). Cohorts characterized by medication non-adherence dominated the majority of MI population with values ranging from 74% to 82%. There were four types of consistent non-adherence patterns as a function of time for each medication class: fast decline, slow decline, occasional users and early gap followed by increased adherence. The characteristics of non-adherence profiles eligible for improvement included patients with a prior history of hypertension, diabetes mellitus and stroke as co-morbidities, and Medicare plan.

CONCLUSIONS

We found consistent patterns of intermediate non-adherence for each of four drug classes for MI cohorts in the order of 56% who are eligible for interventions aimed at improving cardiovascular medication adherence levels. These insights may help improve cardiovascular medication adherence using large medication non-adherence improvement programs.

Clinical characteristics and outcomes of Japanese atrial fibrillation patients with poor medication adherence: A sub-analysis of the GENERAL study

BACKGROUND

Oral anticoagulation therapy is essential for preventing stroke in patients with atrial fibrillation (AF). However, poor anticoagulant adherence may hamper medication safety and effective prevention of stroke.

METHODS

GENERAL is a prospective cohort study of AF patients taking rivaroxaban prescribed by general practitioners in Japan. In this study, anticoagulant adherence was calculated as the proportion of days covered (PDC), and patients were retrospectively divided into two groups: good adherence (PDC ≥80 %) and poor adherence (<80 %).

RESULTS

Of 5680 patients in the GENERAL study, the poor adherence group consisted of 223 patients (3.9 %). Baseline clinical characteristics were almost comparable regarding age (PDC ≥80 % vs. <80 %: 73.9 vs. 74.0 years, p = 0.92) and sex (male 64.6 % vs. 66.8 %, p = 0.52). The PDC <80 % group more often had various co-morbidities, and had significantly higher CHADS₂ (2.14 vs. 2.28, p = 0.04) and CHA₂DS₂-VASc scores (3.12 vs. 3.31, p = 0.045). There was no significant difference in HAS-BLED score (1.41 vs. 1.47, p = 0.39). During 2-year follow-up, the incidences of stroke or systemic embolism (1.14 vs. 3.56 % per patient-year, p < 0.01), major bleeding (0.59 vs. 1.78 % per patient-year, p < 0.01), and net clinical outcome (the composite of stroke, systemic embolism, major bleeding, or death) (3.49 vs. 7.78 % per patient-year, p < 0.01) were significantly higher in the poor adherence group; however, there was no significant difference in all-cause (1.89 vs. 2.73 % per patient-year, p = 0.23) and cardiovascular mortality (0.86 vs. 1.49 % per patient-year, p = 0.18). Multivariate analysis revealed that the poor adherence group was independently associated with stroke or systemic embolism (adjusted hazard ratio 3.12, 95 % confidence interval 1.79-5.47), major bleeding (2.87, 1.31-6.34), and net clinical outcome, (2.02, 1.39-2.93), but not with all-cause (1.18, 0.64-2.17) or cardiovascular death (1.39, 0.60-2.93).

CONCLUSIONS

Poor anticoagulant adherence, as measured by PDC <80 %, was associated with higher incidence of stroke or systemic embolism and major bleeding in the GENERAL study.

Reasons for Nonadherence to the Direct Oral Anticoagulant Apixaban: A Cross-Sectional Survey of Atrial Fibrillation Patients

Background

Nonadherence to direct oral anticoagulants to prevent stroke occurs in up to 40% of atrial fibrillation patients. Underlying reasons are poorly understood.

Objectives

This study quantified patient-reported reasons for nonadherence and identified strategies to improve adherence.

Methods

This is a cross-sectional survey of atrial fibrillation patients in 2 academic health systems who reported apixaban nonadherence. We examined patient-reported reasons for nonadherence and level of nonadherence (assessed by a validated 3-item adherence measure) using a multivariable logistic regression model.

Results

Of 419 study patients, 41.5% were women. The mean age was 71.1 ± 10 years and mean CHA2DS2VASc score was 3.2 ± 1.6. About two-thirds had adherence scores ≥80 (mild nonadherence) and one-third scores <80 (poor adherence). In all groups, forgetfulness contributed to nonadherence. Attitudes/beliefs associated with adherence score <80 included: not believing apixaban was needed (odds ratio [OR]: 12.24 [95% CI: 2.25-66.47]); medication cost (OR: 3.97 [95% CI: 1.67-9.42]); and fear of severe bleeding (OR: 3.28 [95% CI: 1.20-8.96]). Strategies that patients with adherence scores <80 selected as helping "a great deal/a lot" to increase adherence included bloodwork to evaluate efficacy (56%), physician counseling about adherence (55%), and having a reversal agent (39%). Almost one-half of all patients did not disclose nonadherence to their providers.

Conclusions

Patients may not disclose their nonadherence to prescribers, and attitudes related to apixaban nonadherence differ among patients with mild nonadherence versus poor adherence. While all patients may benefit from strategies to address forgetfulness, concerns related to the purpose of apixaban, cost, and bleeding risk may require special attention in those with poor adherence.

Adherence levels and patterns for multiple cardiac medications prescribed to patients with incident atrial fibrillation events

AIMS

Using advanced longitudinal analyses, this real-world investigation examined medication adherence levels and patterns for incident atrial fibrillation (AF) patients with significant cardiovascular and noncardiovascular multimorbid conditions for each of 5 medication classes (β-blockers, calcium channel blockers/digoxin, antiarrhythmics, anticoagulants, antiplatelets). The population was derived from a large cohort covering a wide age spectrum/diversified US geographical areas/wide range of socioeconomic-disability status.

METHODS

The patients were drawn from 3 different health plans. Adherence was defined in terms of the proportion of day covered (PDC), and its patterns were modelled in terms of group-based trajectory, with each pattern profiled in terms of comorbid history, demographic variables and health plan factors using multinomial regression modelling.

RESULTS

The total population consisted of 1 978 168 patients, with the AF cohort being older (average age of 64.6 years relative to 44.7 years for the non-AF cohort) and having fewer females (47.8% relative to 55.4 for the non-AF cohort). The AF cohort had significant cardiovascular/noncardiovascular multimorbidities and was much sicker than the non-AF cohort. A 6-group based trajectory solution appears to be the most logical outcome for each medication class according to assessed criteria. For each medication class, it consisted of one consistent adherent group (PDC ≥ 0.84), one fast declining group (PDC ≤ 0.11) and 4 intermediate nonadherence groups (slow decline [0.30-0.74 PDC range], occasional users [0.24-0.55 PDC range] and early gap/increased adherence [0.62-0.75]). The most consistent adherent groups were much lower than 50% of the total population and equal to 12.5-27.0% of the population, with the fast declining nonadherent pattern in the 5.6-35.0% of the population and the intermediate nonadherence equal to ~61% of the population.

CONCLUSION

Our findings confirm that medication adherence is of major concern among multimorbid patients, with adherence levels lower much than those reported in the literature. There are 3 patterns of intermediate nonadherence (slow decline, occasional users, early gap/increased adherence), which were found to be eligible for interventions aimed at improving their adherence levels for each medication class. This may help improve cardiovascular medication adherence using large medication nonadherence improvement programmes.

Adherence trajectory as an on-treatment risk indicator among drug-resistant TB patients in the Philippines

Introduction

High levels of treatment adherence are critical for achieving optimal treatment outcomes among patients with tuberculosis (TB), especially for drug-resistant TB (DR TB). Current tools for identifying high-risk non-adherence are insufficient. Here, we apply trajectory analysis to characterize adherence behavior early in DR TB treatment and assess whether these patterns predict treatment outcomes.

Methods

We conducted a retrospective analysis of Philippines DR TB patients treated between 2013 and 2016. To identify unique patterns of adherence, we performed group-based trajectory modelling on adherence to the first 12 weeks of treatment. We estimated the association of adherence trajectory group with six-month and final treatment outcomes using univariable and multivariable logistic regression. We also estimated and compared the predictive accuracy of adherence trajectory group and a binary adherence threshold for treatment outcomes.

Results

Of 596 patients, 302 (50.7%) had multidrug resistant TB, 11 (1.8%) extremely drug-resistant (XDR) TB, and 283 (47.5%) pre-XDR TB. We identified three distinct adherence trajectories during the first 12 weeks of treatment: a high adherence group (n = 483), a moderate adherence group (n = 93) and a low adherence group (n = 20). Similar patterns were identified at 4 and 8 weeks. Being in the 12-week moderate or low adherence group was associated with unfavorable six-month (adjusted OR [aOR] 3.42, 95% CI 1.90–6.12) and final (aOR 2.71, 95% 1.73–4.30) treatment outcomes. Adherence trajectory group performed similarly to a binary threshold classification for the prediction of final treatment outcomes (65.9% vs. 65.4% correctly classified), but was more accurate for prediction of six-month treatment outcomes (79.4% vs. 60.0% correctly classified).

Conclusions

Adherence patterns are strongly predictive of DR TB treatment outcomes. Trajectory-based analyses represent an exciting avenue of research into TB patient adherence behavior seeking to inform interventions which rapidly identify and support patients with high-risk adherence patterns.

Lymphocyte trajectories are associated with prognosis in critically ill patients: A convenient way to monitor immune status

Background

Immunosuppression is a risk factor for poor prognosis of critically ill patients, but current monitoring of the immune status in clinical practice is still inadequate. Absolute lymphocyte count (ALC) is not only a convenient biomarker for immune status monitoring but is also suitable for clinical application. In this study, we aimed to explore different trajectories of ALC, and evaluate their relationship with prognosis in critically ill patients.

Methods

We retrospectively enrolled 10,619 critically ill patients admitted to a general intensive care unit (ICU) with 56 beds from February 2016 to May 2020. Dynamic ALC was defined as continuous ALC from before ICU admission to 5 days after ICU admission. Initial ALC was defined as the minimum ALC within 48 h after ICU admission. Group-based trajectory modeling (GBTM) was used to group critically ill patients according to dynamic ALC. Multivariate cox regression model was used to determine the independent association of trajectory endotypes with death and persistent inflammation, immunosuppression, catabolism syndrome (PICS).

Results

A total of 2022 critically ill patients were unsupervisedly divided into four endotypes based on dynamic ALC, including persistent lymphopenia endotype (n = 1,211; 58.5%), slowly rising endotype (n = 443; 22.6%), rapidly decreasing endotype (n = 281; 14.5%) and normal fluctuation endotype (n = 87; 4.4%). Among the four trajectory endotypes, the persistent lymphopenia endotype had the highest incidence of PICS (24.9%), hospital mortality (14.5%) and 28-day mortality (10.8%). In multivariate cox regression model, persistent lymphopenia was associated with increased risk of 28-day mortality (HR: 1.54; 95% CI: 1.06–2.23), hospital mortality (HR: 1.66; 95% CI: 1.20–2.29) and PICS (HR: 1.79; 95% CI: 1.09–2.94), respectively. Sensitivity analysis further confirmed that the ALC trajectory model of non-infected patients and non-elderly patients can accurately distinguished 91 and 90% of critically ill patients into the same endotypes as the original model, respectively.

Conclusion

The ALC trajectory model is helpful for grouping critically ill patients, and early persistent lymphopenia is associated with poor prognosis. Notably, persistent lymphopenia may be a robust signal of immunosuppression in critically ill patients.

Oral anticoagulant adherence and switching in patients with atrial fibrillation: A prospective observational study

BACKGROUND

Adherence to oral anticoagulants (OACs) in patients with atrial fibrillation (AF) is important in preventing stroke. The dominance of retrospective studies using administrative data has led to a lack of data on psychosocial determinants of adherence and prevented comparison of adherence between OAC drug classes. OAC switching is another aspect of adherence that is unexplored.

METHODS

A prospective design was utilized to measure AF patients' self-reported adherence and OAC switching, and to identify their clinical, demographic, and psychosocial determinants. Participants were recruited from specialized AF clinics in Canada and followed for up to 2 years. Data were collected via telephone every 3-4 months using a structured survey. Adherence was measured using the Morisky Medication Adherence scale (©MMAS-8).

RESULTS

The included participants (N = 306) were followed for a median follow up time of 14.1 months and had an average of 3.2(SD 1.4) study visits. The mean self-reported adherence on the ©MMAS-8 was 7.28(SD 0.71) for patients receiving care at specialized AF clinics. Older age, experiencing a bleed, and higher satisfaction with the burden of medications were significantly associated with higher adherence. Drug class did not have any significant impact on adherence. 7.8% of the cohort experienced a switch with most of them being from warfarin to DOAC. Taking warfarin as the index medication, experiencing a bleed and older age were significantly associated with higher odds of switching.

CONCLUSION

Patients with AF reported high adherence to their OAC therapy however being on DOAC may not translate to better adherence compared to VKA. Improving satisfaction with the burden of therapy is important in improving adherence.

Left Atrial Thrombus in Patients With Non-valvular Atrial Fibrillation: A Cross-Sectional Study in China

Background

Stroke is predominately attributed to left atrial thrombus (LAT) in patients with non-valvular atrial fibrillation (NVAF), however, its detection rate in real clinical practice has been few reported in China.

Objective

This study aimed to investigate the prevalence and associated factors of LAT in patients with NVAF in China.

Methods

All adult NVAF patients undergoing transesophageal echocardiography (TEE) in the China Atrial Fibrillation Center database from January 2017 to January 2022 were enrolled in this study. The prevalence of LAT was calculated, and associated factors were identified.

Results

A total of 36,007 NVAF inpatients from 602 hospitals in 30 provinces/autonomous regions/municipalities were included in the final analysis, with a median age of 66 years and 39.4% were female. LAT was present in 1,467 (4.1%) patients overall, 2.7, 5.7, and 6.8% in patients with paroxysmal, persistent, and long-standing persistent AF, respectively. In subgroup analysis, including age ≥ 65 years, CHA2DS2-VASC score ≥ 2, left atrial diameter (LAD) ≥ 50 mm, left ventricular ejection fraction (LVEF) < 50%, and anticoagulation, patients with paroxysmal AF always had the lowest LAT prevalence, followed by patients with persistent and long-standing persistent AF. Patients treated with anticoagulants had less prevalent LAT than those without anticoagulation (2.1 vs. 5.0%, p < 0.001). In multivariate analysis, AF pattern (both persistent AF and long-standing persistent AF), hypertension, chronic heart failure, coronary heart disease, transient ischemic attack/stroke, diabetes mellitus, and LAD (per 5 mm) were associated with an increased prevalence of LAT. However, LVEF (per 5%) and anticoagulation were associated with a reduced prevalence of LAT.

Conclusion

LAT was found in 4.1% of Chinese adult NVAF inpatients underwent TEE in real-world experience. The prevalence of LAT mainly associated with non-paroxysmal AF, cardiovascular diseases, diabetes mellitus, enlarged left atrium, lower LVEF, and lack of anticoagulation therapy.

Editor-in-Chief's Top Picks From 2021

Each week, I record audio summaries for every paper in JACC, as well as an issue summary. This process has become a true labor of love due to the time they require, but I am motivated by the sheer number of listeners (16M+), and it has allowed me to familiarize myself with every paper that we publish. Thus, I have selected the top 100 papers (both Original Investigations and Review Articles) from distinct specialties each year. In addition to my personal choices, I have included papers that have been the most accessed or downloaded on our websites, as well as those selected by the JACC Editorial Board members. In order to present the full breadth of this important research in a consumable fashion, we will present these abstracts in this issue of JACC, as well as their Central Illustrations and podcasts. The highlights comprise the following sections: Artificial Intelligence & Machine Learning (NEW section), Basic & Translational Research, Biomarkers (NEW section), Cardiac Failure & Myocarditis, Cardiomyopathies & Genetics, Cardio-Oncology, Cardiovascular Disease in Women, Coronary Disease & Interventions, Congenital Heart Disease, Coronavirus, Hypertension, Imaging, Metabolic & Lipid Disorders, Neurovascular Disease & Dementia, Promoting Health & Prevention, Rhythm Disorders & Thromboembolism, Vascular Medicine, and Valvular Heart Disease.^1-100.